The anatomy of a hospital

The first new hospital to be built in Israel for 30 years, the Assuta hospital in Tel Aviv is one of the most modern in the World. Its modular components were built in Germany before being shipped and fitted into the concrete frame on site. Israeli systems integrator Barkai has provided an innovative AV distribution and control solution to the hospital.

When Professor Shapiro, general manager of Assuta Medical Centres Ltd set out his wish list for the company’s newest hospital he had four main goals in mind.

“Firstly we wanted it to be possible to use everything done within the Assuta group, on whatever site, to be available in real time to every other one of our sites. If I’m in the middle of a prostate procedure in Tel Aviv, and I want to see the images taken last year in Ashdod, it should be possible immediately and in my operating room.

“A second goal was that everything within the OR should be controllable by each qualified person, in every position in the room. Also, we wanted to be able to easily upgrade or add to the equipment in the hospitals.”

“Finally, the system should be as open and flexible as possible. It should have the ability to be adapted in no time to the needs of each surgeon. We cater for almost 1500 surgeons now and not many of them have the same needs or requirements.”

In the age of PACS, digital patient records and other unified databases, these don’t seem to be such outlandish ideas, but if you know much about medical equipment you will soon realise that the major systems suppliers in the medical world do not produce solutions compatible with these goals.

Consultant Mr Yossi Padva who was hired to look after the low voltage electro-technical systems for the project explained the problem: “The mainstream suppliers all tie you into using their brand of products. If you go with one supplier, then you must use their camera, and overhead lamp and operating table et cetera. Assuta actually uses six different brands of endoscopic camera and it needs to, to cater for all the different surgeons it uses.”

What was really needed was a platform that would enable the hospital to take a number of different video and data sources, and present them on one or more displays within an operating environment, and of course in the audiovisual world, this is bread and butter work. Following a successful tender process, the company given this task was Ramat Gan-based systems integrator Barkai.

The initial requirements from Assuta were actually fairly broad, even vague, so Barkai started out by looking for a suitable platform to build on once more details were hammered out. Shy Kadmon, Barkai’s technical director explained: “The two issues that were immediately apparent were a lack of truly detailed requirements and also an obvious need to keep the cabling to an absolute minimum. We weren’t going to have room for a lot of control and signal cables all over the place as we were going to be competing for ducting real-estate with a lot of other things. We decided that Cat-5 would be the way forward and therefore determined that we would do as much as possible using Crestron’s QuickMedia platform.”

To understand just how tight things would be, it’s worth learning about the construction of the hospital. The operating rooms themselves are actually prefabricated modular constructions, built to specification in Germany and then shipped to Israel before being installed in the building. Everything from the walls of the rooms, to the service booms and arms were pre-built, and pre-cabled abroad. And once assembled, there’s no opportunity to move a hole 20cm to the right.

But that’s enough about problems, this is a solutions business. Shy Kadmon explained the broad arrangement of the system. “The surgical complex consists of sixteen operating rooms on a single floor. They are grouped into four sections, divided by the various types of procedures performed there. Each group of rooms is served by a pair of racks, holding two AV systems. So essentially each pair of rooms shares one system, with the exception of the MRI room, which has its own rack, because it’s electrically isolated. In addition there is a central rack which handles routing and switching between the other groups, and the rest of the hospital building. In total we have six equipment rack positions. In reality the hospital could have opted to have a single system for each OR, or shared one between four ORs, it came down to a cost / reliability consideration. One rack per room was too expensive, and one between four was considered too risky in the case of a system failure.”

The systems serving each pair of ORs are largely the same. Inside each operating room there three booms suspended from the ceiling. As well as services such as gas outlets, and power sockets, each boom supports a 19” Elo medical grade touch panel, which provides the main interface to the system. Mounted in the back of the panel is a Crestron QuickMedia RX module, and an additional Gefen RS-232 over Cat5 extender. This latter item was necessary to support the touch screen input – Crestron does not yet supply a medical grade touch screen. As well as a touch panel, each boom might also hold an endoscopic camera arrangement, or the anaesthetists PC or simply trays for surgical instruments. There is a fourth Elo panel mounted in the wall of each OR, and the finally the larger “cockpit” screen.

This is a 50” medical grade LCD from DTS in the US, they were the only supplier Barkai could come across able to supply such a device with 1080p resolution.

“We ran quick media to this as well,” explained Kadmon. “The idea is that they can put whatever they want on here. It’s not actually a touch panel but we used Crestron’s DVP-HD scaler to generate a split screen view of up to eight different elements.

“One requirement was to show the gas gauges. Instead of just a straight video feed, we used the capabilities of the DVP-HD as a interface controller to generate dynamic gauges using data straight from the building’s gas supply, by interfacing with the MODBUS network.”

The touch panel really is the most important piece of the puzzle, and Barkai spent considerable effort on getting both the GUI and the functionality just right for the surgeons. The company’s project manager Itzik Hoch commented: “We had so many different phases of GUI design. If we do a boardroom, we make a design and then give it to the customer who make a few changes. With the hospital we didn’t have a clue what they really needed so we had to talk to doctors and to the hospital general manager and make sure they were happy. This took a long time.”

The list of available functionality and sources on the touch screens also explains the amount of time spent on the GUI. There is the option to view sources from remote microscopy laboratories, the endoscopic camera and video conferencing codec. Patients’ vital readings, the gas gauges, an operation timer clock and warnings from the hospitals fire alarm systems can all be displayed. Control wise, the user has full command of the room’s lighting levels, the main overhead light, door access control, the air conditioning and even media playback (Barkai installed iPod docks in the racks so that surgeons can listen to their choice of music during procedures). All of this had to be integrated into an interface that could be used by a huge number of different users.

Each two-room system is held together by a Crestron 161x16 quick media matrix. On the input side of this is a pair of DVP-HD scaler / controllers (one for each room) and the other video sources for the ORs. These include PCs, the endoscopes, the overhead and videoconference cameras and also inputs from the pathology labs. Outputs from the QM 16x16 include the five displays in each OR and a send to the main control rack.

On the lighting control and audio side of the rack, the master controller is a single Crestron MC2E shared between the two ORs. This governs a pair of dimmer arrays for the ceiling lights and relay controls for the door system and surgery lamps.

Handling audio routing and processing is a Biamp AudiaFLEX. A cobranet network operates around the operating floor, and for video conferencing Barkai also installed an AEC-2 card for acoustic echo cancellation.

Sources for the AudiaFLEX box include a microphone in each OR for VC purposes, the iPod interfaces in the rack and inputs from the VC codec. Audio outputs in the operating room are simply a pair of WHD Marine series loudspeakers. These were chosen for their water resistance for cleaning purposes. When it came to powering them Barkai found that they were starting to run out of rack space. A solution presented itself in the shape of InOut audio’s rack mount amplifiers. Kadmon explained: “We didn’t need much power, we wanted something small, reliable and controllable that we could integrate into Room View later on.” InOut’s RS-232 port and half rack width fitted the bill perfectly.

It’s hard to disguise how impressed I was with this installation. It’s a true systems integration job. And whilst it perhaps seems obvious to an AV integrator that all of these systems could be tied together via a central platform, to the medical profession this is still new ground. They are used to packaged solutions from major vendors (irony noted) which are not just hard, but impossible to integrate with gear from other people. The application of sound AV theory to what is a completely new market for Barkai has left the customer extremely pleased with the result, and opened up new ground for the company.

“We learned a whole new language on this project,” said Kadmon. “It’s an incredible reference for us. Doctors from all over Israel are coming to see what we have done.”

Assuta’s general manager Prof. Shapiro had the final word on the matter: “Flexibility has always been one of our greatest strengths. This is the first hospital we have built, which will give us the capability to easily change and update its equipment during its life time.”

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